April 7, 2020
Despite Pandemic Challenges and Anxiety, Clinicians Are Stepping Up to Deliver Care and Support Colleagues
Originally published in NEJM Catalyst. Namita Seth Mohta, MD, interviews John D. Birkmeyer, MD, Chief Clinical Officer, Sound Physicians; Adjunct Professor, The Dartmouth Institute for Health Policy and Clinical Practice.
Namita Seth-Mohta: This is Namita Seth-Mohta for NEJM Catalyst. I am speaking today with Dr. John Birkmeyer, Chief Clinical Officer for Sound Physicians and Adjunct Professor at the Dartmouth Institute for Health Policy and Clinical Practice. Sound Physicians is a multispecialty provider group of approximately 3,500 providers in emergency, inpatient, and intensive care, working with over 250 hospitals.
Dr. Birkmeyer and I will talk today about the Covid-19 pandemic from the perspective of a provider group. Our objective is to discuss care delivery — the very mission of NEJM Catalyst — during a unique and defining moment. Our goal is that our listeners leave with insights that they apply not only to their own Covid response plans, but also to their longer-term care redesign efforts to improve outcomes for the patients and communities they serve.
Thank you for joining us today, Dr. Birkmeyer.
John Birkmeyer: Good morning. Thank you for having me.
Mohta: For context, tell us a little bit about Sound Physicians. How do you work with hospitals to provide care, what types of hospitals, and in what geographies?
Birkmeyer: Sound Physicians is a national medical group specializing in hospital-based care. We work with hospitals under direct contracts, whereby we provide them with both provider staffing and performance management services. We tend to work most commonly with large community hospitals, typically ranging in bed size from 100 to 600 beds. We’re spread out pretty evenly across the country in about 40 states right now.
“The greatest commonality is intense anxiety — anxiety among our clinicians, but also anxiety on the part of our hospital partners and the executives with whom we partner.”
Relative to the Covid-19 conversation, we do not have a significant footprint in the five boroughs of New York City, but we do have large concentrations of physician practices in both Washington state and California.
Mohta: What has been your experience with Covid-19 so far?
Birkmeyer: Covid-19, as we have seen with many of the hospitals with which we’re both familiar, has really taken off, and it’s distracting both physician groups and hospitals from everything else that they’re doing. There’s a lot of uncertainty regarding the size of the Covid populations that Sound Physicians has been managing, but based on our most current real-time estimates, we’ve admitted and still have in the hospital almost 3,000 patients* [as of March 24, 2020; as of April 1, 2020, there are approximately 8,000], although this is almost certainly an undercount.
Mohta: You have the unique perspective of watching Covid-19 unfold in multiple regions, in multiple hospitals across the country at the same time. What are some constants and what are some significant differences?
Birkmeyer: By far, the greatest commonality is intense anxiety — anxiety among our clinicians, but also anxiety on the part of our hospital partners and the executives with whom we partner. Among the most common pain points that all of our hospitals are experiencing is imperfect dissemination of information about how clinicians can best protect themselves and perceived — and in most cases, very real — shortages of personal protective equipment [PPE], particularly N95 masks.
We’re seeing across almost all our partner hospitals significant disruptions in non-Covid care. While this effect is more pronounced in some hospitals than others, across the country, we’re seeing overall hospitalization rates that are at least 15% down from where they were before the epidemic, and while some of that is attributable to some of the obvious suspects, like [postponing] elective surgery, we’re seeing significant declines in the rates by which patients are presenting to the emergency department, but also being hospitalized for acute medical illness, presumably patients with lower-acuity acute medical illness.
“I’ve detected some cultural differences and, in some ways, a red state/blue state divide in the urgency in the approach by which hospitals are preparing themselves for Covid.“
One of the things that’s been most interesting to me is the heterogeneity by which hospitals and hospitals in different regions are approaching the epidemic, and some of that variation may be attributable to important differences in disease prevalence and how real the Covid-19 epidemic has become by now. I’ve detected some cultural differences and, in some ways, a red state/blue state divide in the urgency in the approach by which hospitals are preparing themselves for Covid. In some of the more metropolitan, what I call blue state areas, hospitals tend to be more proactive, are being more aggressive regarding quarantining not just patients with direct exposures, but sometimes clinicians with only indirect exposures to patients with potential Covid infection. In hospitals with either lower prevalence or located in what we think of as the red state parts of the country, I think that there’s a slightly more fatalistic perspective on the epidemic and probably a strategy that tends more toward the reactive rather than the proactive side.
Mohta: I want to explore your earlier comment about some common themes and your mention about how disruption in non-Covid care is prevalent throughout. Say a little bit more about why you think the decline in presenting to ED and admissions is happening.
Birkmeyer: My best hypothesis for why overall hospital volumes are down is that patients and their families, in partnership with their primary care physicians, are rightly apprehensive of presenting to the emergency department or entering any types of health care facilities, whether they’re acute care hospitals, SNFs [skilled nursing facilities], or otherwise, at a time where they don’t absolutely need to. As I look across our own data, that 15% decline in overall hospitalization rates already is spread out across all types of diagnoses, not just surgery, but congestive heart failure, COPD, and a lot of the other common reasons why patients get hospitalized.
There are two unanswered questions at this point that are implicit in your question. The first is, are we simply postponing and building a pent-up demand for elective and quasi-elective care that we’ll, at some point, have to deal with once this epidemic passes? Number two, will our response to the Covid-19 epidemic and hospital saturation have real and measurable impacts on patients? I come from Dartmouth,2 so I’m aware of the upsides associated with keeping patients out of the hospital when they don’t need to be there, but I also imagine significant risks of under-care of patients with acute strokes and other needs that will inevitably be underserved.
“Will our response to the Covid-19 epidemic and hospital saturation have real and measurable impacts on patients?“
Mohta: We need more data, as you’re suggesting, to explore some of these unknowns between under-care versus avoidance of unnecessary care for some of these non-Covid-related illnesses. You already have alluded to some of the sophisticated data analytics capabilities that your organization has. Tell us a little bit more about that and how you’re using analytics to manage your day-to-day operations and response to the pandemic.
Birkmeyer: Sure, happy to. One of the advantages of a national-scale medical group is the ability to make investments, particularly in IT systems and in analytics. Toward that end, Sound has traditionally employed advanced analytic capabilities to improving care with all sorts of other populations. Our major focus in reacting to the Covid-19 epidemic has been to retool our nationwide IT platform to track in real time which patients have Covid in the presence or absence of testing confirmation. That same IT tool not only applies to patients that have Covid but simplifies our team’s approach to be able to concentrate those patients on specific teams and in specific parts of the hospital.
The other advantage of that type of real-time tracking, particularly given all of the fluidity involved in growth in admission rates, is that it allows Sound as a national organization to better keep its finger on the pulse of the epidemic. Specifically by us appreciating what the prevalence is at any one of our sites, it allows us to tailor our support to the hospital sites and to the physician teams that need that most. Sometimes that support focuses on the availability of PPE equipment — and specifically, where we can, backstopping shortages of N95 masks. But that type of support also extends to providing emotional support and well-being services to physicians who are significantly stressed.
Mohta: Can you share with us a tangible example of how you’re using the data and then providing specific supports to physicians who might need extra support at this time, in terms of well-being and mental health support?
“There’s no doubt in my mind that telemedicine is here to stay after the pandemic.“
Birkmeyer: Every morning, I get a real-time assessment of the current number of Covid-bedded patients at every one of our hospitals. Right now, we have  hospitals that have more than 50 bedded patients [current hospital medicine and ICU inpatients]. We have another  hospitals with between  and 50 bedded patients. [As of April 1, 2020, 3,000 patients are bedded, with 550 admitted in the past 24 hours.] That information gets funneled to a central support team that manages both clinician support and takes over supply chain functions. Specifically, when we identify our 12 or 15 hot-spot hospitals, our central team reaches out directly to those physician chiefs to assess how they’re holding up, what has been the impact on individuals on your team, both medically and otherwise, and what can we do to help?
On the PPE front, being able to identify where the epidemic is hitting first allows us to, in real time, do surveys for the current inventory of hospital-supplied N95 masks and other crucial equipment. When we have early forecasts of shortages or absences of that equipment, we try to ship supplemental supplies to help.
Mohta: Is it too early to tell whether telemedicine is here to stay after this pandemic is over?
Birkmeyer: There’s no doubt in my mind that telemedicine3,4 is here to stay after the pandemic. Certainly, we’ve had rapid growth in both the demand for telemedicine’s services from hospitals and in the interest of physicians in being part of those types of practices even before the Covid-19 epidemic. As such a large number of hospitals move toward rapid deployment in the context of the short-term need, I think that it will break down a lot of the historical barriers to the use of telemedicine, particularly on issues related to its perception, its acceptance by patients, its acceptance by bedside nurses, and the logistical difficulty of getting it in place.
Mohta: Let’s pause for a moment to talk about challenges. How does the fact that you are a national independent physician organization make the job of addressing the pandemic harder or easier than if you were an organization affiliated with or employed by a specific health system?
Birkmeyer: We certainly have advantages associated with our large national scale. Obviously, we can speak with one voice. We can rapidly deploy campaigns for physician education and speak with a single voice. As we’ve already discussed, there are obvious advantages in being able to invest in information technology and analytics that facilitate overall changes in care in new patient populations.
“A lot of what we’ve seen over the last couple of weeks has given me some renewed faith and admiration in the professionalism, in the sense of duty of physicians.”
But there are some challenges associated with trying to navigate a crisis like Covid-19 as a national physician group. The most important is that Sound Physicians, like its peer groups, contracts with hospitals; in many ways, we cede control over policy and supply chain management to our hospital partners. Don’t get me wrong, we have great hospital partners, but inevitably there is variation in how fast they move, in how sophisticated they are in the types of resources that they could bring to bear. In many cases, we’ve been a useful adjunct in helping accelerate their own learning, but in other cases, there have been struggles.
Mohta: To end on a positive note, share with us a success story from these last few weeks.
Birkmeyer: I’ll tell you at a high level, in all sincerity, a lot of what we’ve seen over the last couple of weeks has given me some renewed faith and admiration in the professionalism, in the sense of duty of physicians. It’s easy, particularly as a seasoned health services researcher, to take a somewhat cynical view of some aspects of the medical community, and without a doubt, this has been a time of crazy anxiety across the country, not the least of which with clinicians. We’ve certainly seen, in pockets, in small numbers of individuals, physicians who decided this was the right time to go on sabbatical, to otherwise go AWOL, to demand combat pay for seeing patients given their risk. But what’s been most surprising and most gratifying to me is that that type of behavior has actually been very rare, and what we’re seeing much more commonly is small acts of heroism, ranging from physicians volunteering to work extra shifts to cover for their partners who have either gotten sick or are quarantined, to physicians in Texas who are volunteering to temporarily relocate to help out in Seattle, and even quarantined docs who are offering, in their physical absence, to help care for patients via telemedicine. A lot of great stories.
Mohta: Thank you so much, Dr. Birkmeyer, for joining us today.
Birkmeyer: Thank you for having me.
*Editors’ note: This podcast was recorded on March 24, 2020.
John D. Birkmeyer, MD, Chief Clinical Officer, Sound Physicians; Adjunct Professor, The Dartmouth Institute for Health Policy and Clinical Practice
Namita Seth Mohta, MD, Executive Editor, NEJM Catalyst; Assistant Professor of Medicine, Harvard Medical School